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README - Server Config

Description: DO NOT ATTEMPT TO INSTALL WITHOUT READING THESE INSTRUCTIONS. Your iRoam tour will no longer be hosted for you. To continue
Url: /Media/UHS-website-2019/Videos/SouthamptonNeonatal/SouthamptonNeonatal/README-Server-Config.pdf

Justifying termination of pregnancy

Description: The court considers whether termination of pregnancy is in the best interests of a young woman who lacks capacity.
Url: /HealthProfessionals/Clinical-law-updates/Justifying-termination-of-pregnancy.aspx

UHS adult major trauma guidelines

Description: Adult Major Trauma Guidelines University Hospital Southampton NHS Foundation Trust Dr Mark Baxter Director of Major Trauma, Consult
Url: /Media/SUHTExtranet/WessexTraumaNetwork/UHS-adult-major-trauma-guidelines.pdf

Resources

Description: Auto Generated Title Take a look through our useful resources, helping you fund your research, keep up to date and access the informa
Url: /ClinicalResearchinSouthampton/For-researchers/Education-and-training/Resources/Resources.aspx

Papers Trust Board - 10 September 2024

Description: Agenda Trust Board – Open Session Date 10/09/2024 Time 9:00 - 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Papers-Trust-Board-10-September-2024.pdf

Welcome to Ward E2 Easy read - patient information

Description: Easy read information about Ward E2
Url: /Media/UHS-website-2019/Patientinformation/Heartandlungs/Welcome-to-Ward-E2-Easy-read-3488-PIL.pdf

Annual-report-2018-19

Description: ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2019 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Welcome from our Chair 7 A word from the chief executive 8 Overview of the Trust Statement of purpose and activities 9 History of UHS 9 Our executive team structure 10 Structure of our services 11 Our vision and values 12 Our priorities, key issues and risks 13 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 17 How we monitor performance 18 Detailed analysis and explanation of the development and performance of UHS 18 Regulatory body ratings 23 Environmental matters 24 Social, community, anti-bribery and human rights issues 25 Accountability report Members of the Trust Board 27 Trust Board purpose and structure 31 Board meeting attendance record 2018/19 32 Well-led framework 33 Strategy and finance committee 34 Quality committee 34 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 36 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 37 Disclosures 37 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 40 Annual remuneration statement 49 Remuneration and appointments committee 52 Governors’ nomination committee 54 Staffing report 58 Staff survey results 62 Trade union facility time 66 Statement of chief executive’s responsibilities as the accounting officer 69 Annual governance statement 70 Voluntary disclosures Equality, diversity and inclusion 78 Environmental sustainability and climate change 80 Southampton Hospital Charity 84 Developments in informatics 85 Leading research into better care 85 Investing for the future 86 Quality account and quality report 2018/19 Chief executive’s welcome 88 Our approach to quality assurance 90 Our commitment to safety 90 Duty of candour 91 Our commitment to staff 91 Freedom to speak up 94 Our commitment to education and training 95 Our commitment to staffing rota gaps 96 Our commitment to technology to support quality 97 Our commitment to the Care Quality Commission 98 Our commitment to improving the environment for our patients 100 Review of quality performance 101 Clinical research 101 Review of services 102 CQUIN payment framework 103 Data quality 103 Participation in national clinical audits and confidential enquiries 104 How we are implementing the priority clinical standards for seven day hospital services 105 Learning from deaths 106 Progress against 2018/19 priorities 109 Priorities for improvement 2019/20 128 Conclusion 132 Responses to our quality account 133 Statement of directors’ responsibilities 138 Independent auditor’s report 139 Quality account appendix Appendix 1: Our quality priorities 2019/20 143 Appendix 2: Quality performance data 144 Appendix 3: CQUIN data 151 Appendix 4: Clinical audit and confidential enquiries data 154 Appendix 5: British Society of Urogynaecology 156 Appendix 6: National clinical audit: actions to improve quality 157 Appendix 7: Local clinical audit: actions to improve quality 161 Appendix 8: Shared decision making 173 Appendix 9: Registration with the Care Quality Commission 174 Annual accounts Statement from the chief financial officer 177 Foreword to the accounts 178 Independent auditor’s report 179 Financial accounts and notes 186 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2018/19 was a year of change in the leadership of UHS. Following the departure of Fiona Dalton in March 2018 to run a hospital group in Canada, David French took on the role of interim chief executive officer. On behalf of the Trust Board I would like to thank David for agreeing to do so and also for doing such an outstanding job. During the year we welcomed three new non-executive directors to the Trust; Jane Bailey, Professor Cyrus Cooper and Catherine Mason. Catherine’s talents were also recognised by Solent NHS Trust and she has since left to help lead their organisation as chair. We were delighted to welcome Paula Head as chief executive in September after a rigorous and robust recruitment process. Paula’s experience as chief executive of Royal Surrey County Hospital NHS Trust and, prior to that of Sussex Community NHS Foundation Trust, shone through and we were confident that under her leadership UHS would continue to develop, grow and improve. Demand for our services continues to rise rapidly as the result of a changing demographic and other factors, and at a rate far greater than our income. Despite this our staff continue to deliver exceptional care. I was delighted that this was recognised by the Care Quality Commission in their recent inspection when they again rated us as Good. The revised NHS Long Term Plan will inevitably require us to adapt to the changing pattern of healthcare, but we do so with enthusiasm. This year has shown just how adept we are as an organisation at responding positively to change, not only rising to the challenges it presents, but thriving with it. This is evident in the significant investments we have made in the Trust’s estate this year. Phase one of our new children’s emergency department is complete thanks to the continued support of the Murray Parish Trust. We also approved one of the largest capital investments in our history with the updating and expansion of our general intensive care unit. We recognised that it was as crucial to invest, not just in the physical environment within which we provide healthcare, but within the digital environment too, acknowledging that UHS is an NHS digital exemplar. We have invested significantly in information technology to enhance accessibility and improve both patient and staff experience. We look forward with confidence to helping lead the NHS into a new phase of delivering health and care for the United Kingdom into 2019/20. Peter Hollins Chair 7 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive Since arriving at UHS to take up my position as chief executive officer, I have heard and witnessed some incredible achievements by staff at the Trust. Dr Joanne Horne was named biomedical scientist of the year at the Advancing Healthcare Awards for her work in histopathology; Dr Beth McCausland, quality improvement fellow in dementia care, was named foundation doctor of the year by Royal College of Psychiatrists; Sarah Charters, consultant nurse and mental health lead for the emergency department was awarded an MBE for services to vulnerable adults and her vulnerable adult support team were also winners of a Nursing Times Award in the emergency and critical care category. The medicine for older people therapy team led by Hannah Wood was named most inspiring team at the national #EndPJParalysis awards while Marie Nelson, matron in research and development, and senior research sisters Jane Forbes and Kirsty Gladas won the silver award for clinical research site of the year at the PharmaTimes International Clinical Researcher of the Year Awards. Jean Piernicki, senior nurse manager in occupational health, was awarded the title of Queen’s Nurse in recognition of her high level of commitment to patient care and nursing practice. Fiona Chaâbane, a senior clinical nurse in neurosciences was named winner of the nursing and midwifery award at the BBC’s The One Show Patients Awards. The medicines advice service, led by Dr Simon Wills, picked up the HSJ Value Award for training and development for its medicines learning portal and Matthew Watts, head of news, was named operational services support worker of the year for the south of England at the Our Health Heroes Awards 2018. We were also delighted that the energy and sustainability team collected the clinical NHS Sustainability Award for its green wards project. These are just a few of the individual and team successes achieved this year. Our entire organisation can also be incredibly pleased and encouraged by the outcome of the recent Care Quality Commission (CQC) inspection, which rated UHS ‘good’ overall, with many individual areas being recognised as outstanding by the CQC. You can find full details of the inspection on page 98 of the quality account. Such positive inspection results link to equally positive staff survey results which saw UHS ranked as the second highest acute trust for staff satisfaction and fifth highest for staff recommending the Trust as a place to work and receive treatment. It’s made me incredibly proud to be able to say that I am part of such a driven team and it’s clear that the UHS team share my drive and determination to improve things for patients and staff every day. This is evident in both the successes I have already mentioned, but also in the pioneering work that is taking place across every department. Informatics has been pioneering new digital initiatives which they recently shared with Hadley Beeman, chief technology adviser to the secretary of state and social care. Surgeons Bhaskar Somani and Stephen Griffin have created a ‘twin surgeon’ model that has revolutionised the treatment of kidney stones in children. Dr John Paisey, consultant cardiologist, and his team were among the first in the world to implant and programme a pacemaker using Bluetooth technology. They performed four of the first five procedures in the world. While Professor Mike Grocott and his team created ‘surgery school’ which is transforming the fitness of patients prior to their operations and thereby reducing length of stay. These are by no means the entirety of our achievements this year and I would like to take the opportunity to thank every single member of staff at the Trust who continues to make UHS one of the leading trust’s in the UK. Paula Head Chief executive officer 8 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 11,900 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2018/19 was more than £878m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). 9 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Associate director of corporate affairs (interim) Charlie Helps Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive Paula Head Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services; communications Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer & deputy chief executive David French Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 10 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 11 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 12 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 13 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 14 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2019/20. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 31. Audit and risk committee Strategy and finance committee Quality committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section on page 70. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. 16 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2018/19 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk 17 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2018/19 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers, including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2016/17 to 2018/19 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases) 2013/14 2016/17 Outpatient appointments 2017/18 2018/19 ED attendances (type one) Referrals (excl March) Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals (excl March) 2016/17 160,000 630,045 99,273 189,194 2017/18 157,993 658,147 104,616 197,522 2018/19 168,791 695,343 110,771 207,209 Increase 2016/17 to 2018/19 5.5% 10.4% 11.6% 9.5% 18 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven, in 2017/18 this increased to twenty, however in 2018/19 there were no black alerts. The chart below shows red alerts logged during 2018/19. Red alerts 2018/19 60 Number of AM and PM alerts 45 30 15 0 4/1/18 6/1/18 8/1/18 10/1/18 12/1/18 2/1/19 Contributing to this change has been an increase in day cases and an increase in length of stay (LoS) for elective patients linked to a more complex case mix. UHS delayed transfers of care 2018/19 The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2018/19. 3,600 Percentage of bed days lost 3,200 2,800 2,400 2,000 April 2018 June 2018 August 2018 October 2018 December 2018 February 2019 19 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS did not meet the target this year. Achievement of this target in 2018/19 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. The Trust has finished the financial year with no patients waiting greater than 52 weeks, and a total referral to treatment waiting list lower than in March 2018. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and all three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard states that 95% of patients should be treated and either admitted or discharged within fours of arrival into ED. However, NHS Improvement set local targets for all NHS organisations with an ambition that the NHS would return to meet the 95% target by March 2019. The local targets set by quarter (to allow for seasonal variations) for UHS were: Quarter 1 - 90% Quarter 2 - 91.4% Quarter 3 - 90% Quarter 4 - 90-95% How did we do? 2018/19 was another challenging year for emergency patients for the whole Hampshire and Isle of Wight area. Whilst we had a positive start to the year achieving quarter 1 and 2 targets, we did not meet quarter 3 or 4 targets. We did, however, meet out local delivery system targets. 20 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year (including all UHS types and Lymington). National 4 hour access target – UHS performance 100% 95% 90% 87.1% 85% 80% 82.1% 82.3% 87.4% 87.4% 93.0% 90.5% 84.7% 82.9% 85.7% 90.7% 88.9% 84.8% 77.9% 81.1% 75% Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 The graph below shows our local delivery system performance against the four hour target over the last year (including all SGH types, Lymington and Southampton Treatment Centre). National 4 hour access target – Local delivery system 100% 95% 91.0% 90% 91.1% 95.1% 92.8% 88.7% 87.1% 89.2% 91.5% 85% 92.9% 88.4% 83.3% 85.9% 80% 75% Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 21 OVERVIEW AND PERFORMANCE REPORT Cancer waiting times There are nine separate cancer waiting times standards (below), each of which can then be split into tumour site specific performance groups. Measures Urgent GP referrals seen in two weeks Breast symptoms referral seen in two weeks Treatment started within 62 days of urgent GP referral Treatment started within 62 days of referral (breast, cervical and bowel screening) 62 day consultant upgrades Treatment started within 31 days of decision to treat Second or subsequent treatment (surgery) started within 31 days of decision to treat Second or subsequent treatment (anti-cancer drugs) started within 31 days of decision to treat Second or subsequent treatment (radiotherapy) started within 31 days of decision to treat Target > 93% > 93% > 85% > 90% > 86% > 96% > 94% > 98% > 98% 18/19 YTD (up to and including Feb 19) 86% 50% 74% 80% Achieved 8 8 8 8 86% 3 93% 8 85% 8 100% 3 100% 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 7.7% in 2018/19. The chart below shows the rise in demand for UHS cancer services over the past three years UHS growth in cancer actvity – 2016/17 to 2018/19 (up to and including month 11) 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 2016/17 up to and incl Feb 62 day target patients 31 day target patients 2017/18 up to and incl Feb 2018/19 up to and incl Feb For staffing performance, please refer to page 58. For financial performance please see page 177. Paula Head, chief executive officer 28 May 2019 22 OVERVIEW AND PERFORMANCE REPORT Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2018/19 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2019. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good 23 OVERVIEW AND PERFORMANCE REPORT In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital we undertake a wide range of activities and use a large amount of resources, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 80 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 24 OVERVIEW AND PERFORMANCE REPORT Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. 25 FR STAND BODY ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT; Member of Solent Acute Alliance; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel (from May 2018) Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Husband is a consultant surgeon in the Trust; Daughter is a midwife at UHS (from March 2019) Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father and mother are UHSFT simulated patients (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Daughter is employed within the emergency department at UHS (from 1 August 2018) 27 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Simon Porter Senior independent director and deputy chair Dr Mike Non-executive Sadler director Biography Declarations Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of
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Annual report 20-21

Description: 2020/21 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2020/21 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2021 University Hospital Southampton NHS Foundation Trust Table of contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 29 Directors’ report 30 Remuneration report 53 Staff report 65 NHS Foundation Trust Code of Governance 81 NHS Oversight Framework 81 Annual governance statement 84 Quality report 95 Statement on quality from the chief executive 96 Priorities for improvement and statements of assurance from the board 99 Other information 153 Annual accounts 180 Statement from the chief financial officer 181 Auditor’s report 182 Foreword to the accounts 188 Statement of Comprehensive Income 189 Statement of Financial Position 190 Statement of Changes in Taxpayers’ Equity 191 Statement of Cash Flows 192 Notes to the accounts 193 5 Welcome from our chair and chief executive 2020/21 was undoubtedly the most challenging year in the history of the NHS, and we have felt the impact of the COVID-19 pandemic here at University Hospital Southampton NHS Foundation Trust (UHS) in full. Responding to this has meant there isn’t a single part of our organisation that hasn’t changed in some way over the last year and we have all had to adapt to a rapidly changing environment. Our staff have been unwavering in their dedication, hard work and commitment to keeping our hospitals running, our patients cared for, and their colleagues supported. Every single member of the UHS family has played their part. The loss of life from COVID-19 has been devastating, and at UHS we stand shoulder-to-shoulder with everyone affected by this tragedy, including the families of staff members whom we lost. We must recognise the incredible work of Southampton Hospital Charity, which has funded boost boxes, wellness rooms, a helpline and so much more to support staff at a time when their wellbeing is more important than ever. As the nationwide vaccination programme continues to offer hope of life more like pre-pandemic times, we are proud to have been at the forefront of these efforts - from being part of early research for the Oxford-AstraZeneca vaccine, to the opening of one of the largest vaccination hubs in the region on our site in December 2020. We will continue to play a key role in vaccination development by leading the world’s first clinical trial into the effectiveness of COVID-19 booster vaccines, as well as taking part in a study involving pregnant people. Our response to COVID-19 has prompted innovation and new ways of working across the Trust, to the benefit of patient experience. At the start of the pandemic we faced real challenges of capacity and increases in waiting times, which led to us working with Spire Southampton so cancer treatment and surgery could continue for patients at highest risk. We also increased the number of outpatient attendances which took place by telephone or video call, and our patient support hub was set up to provide a single point of support for patients who had been advised to shield. We are immensely proud of the record of the Trust during the pandemic, exemplified by the number of patients we were able to take into our care from well outside the local area. The Trust is in a strong financial position as a result of careful spending and efficiencies, which has allowed us to invest significantly in upgrading our estate. These improvements have seen the opening of the general intensive care unit, and the new cancer ward, which was built in just six months. These formed part of overall capital expenditure of £80 million during the year. The last year has seen us say goodbye to two members of our executive leadership team. Paula Head left the chief executive officer role in November to join the national response to COVID-19, before becoming a senior fellow at The King’s Fund. Derek Sandeman moved on from being our chief medical officer to take the same position at the Hampshire and Isle of Wight Integrated Care System. We are grateful to both for their efforts on the Trust leadership team during the most challenging of years. One of our non-executive directors, Jenni Douglas-Todd, also left the Trust to take on the important role of director of equality and inclusion with NHS England and NHS Improvement. 6 Looking ahead to the future, UHS will play a key role in the Hampshire and Isle of Wight Integrated Care System. Our commitment is to deliver services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries for seamless patient care. We as a Trust board are looking forward to implementing our own five year strategy, which sets out ambitions for what we want the hospital to be in 2025, for both patients and staff. Our focus will always be on enabling world class people to deliver world class care. Peter Hollins David French Chair Chief Executive Officer 7 OVERVIEW AND PERFORMANCE Performance report Introduction from our chief executive Over the last year, the way in which the Trust has worked and performance it has achieved, has been transformed by the COVID-19 pandemic. • UHS saw a number of large surges in demand for inpatient care, and for intensive respiratory support in particular, due to COVID-19 infection rates. Our capacity to deliver intensive care had to be increased, and many of our staff moved from other services such as our elective theatres in order to meet this need for care. • We have introduced and continue to maintain a number of changes to reduce the risk of COVID-19 being transmitted, or adversely affecting patient outcomes, within the Trust. Changes have included the wearing of additional personal protective equipment by our staff (especially when caring for patients who might have COVID-19 or undertaking higher risk procedures), reducing the number of patients coming to our outpatient departments and increasing the number of telephone and video consultations, separating elective and emergency patients within our departments and regular testing of our staff and all patients on or prior to their admission to hospital for treatment. • Public concerns about safety, government restrictions and the efforts of community services actually contributed to reductions in the total number of patients who sought hospital care this year. • Treatment plans have been modified by a number of services, in partnership with patients, to reduce the risk posed by COVID-19 to those patients. This was often appropriate in those circumstances in which the normal treatment would significantly reduce the patient’s own resistance to infections. Our performance has, in many cases, been strongly influenced by these profound changes. We have responded well to the need to provide the most urgent care, and the adverse impacts on elective care have been slightly less than the average across the NHS. However, we remain very concerned by the significant increase in the numbers of patients waiting longer than they should for elective care. It will take concerted and sustained action within both the Trust and the wider NHS in order to return elective performance to levels achieved before the pandemic whilst also continuing to meet urgent care needs as the restrictions that have been implemented within our society are progressively relaxed. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2020/21. It is based on the coast in south east England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health Research (NIHR), Wellcome Trust and Cancer Research UK. UHS is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and in the top ten nationally for research study volume as ranked by the NIHR Clinical Research Network. 12,000 Every year over staff at UHS: treat around 160,000 inpatients and day patients, including about 75,000 emergency admissions see over 650,000 people at outpatient appointments deal with around 150,000 cases in our emergency department deliver more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it offers a safe, ‘home away from home’ environment for women having a healthy pregnancy and expecting a straightforward birth. The services provided by the Trust are commissioned and paid for by local clinical commissioning groups (CCGs) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Over 50% of UHS services are paid for by CCGs and approximately 48% by NHS England. We provide these under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by Monitor (the independent regulator, now part of NHS England and NHS Improvement) and the healthcare services we provide are regulated by the Care Quality Commission. Being a foundation trust has enabled greater local accountability and greater financial freedom and has supported the delivery of the Trust’s mission and strategy over a number of years. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Division B Division C Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Division D Trust Headquarters Division Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Corporate Affairs Communications Estates, Facilities and Capital Development Finance Human Resources Informatics Patient Support Services Procurement and Supply Transformation and Improvement (‘Always Improving’) Research and Development Strategy and Business Development 11 The Trust is also part of an integrated care system in Hampshire and the Isle of Wight, which is a partnership of NHS and local government organisations working together to improve the health and wellbeing of the population across Hampshire and the Isle of Wight. Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/2021 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to continue on its journey to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these describes a number ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care. Pioneering research • We will recruit and enable people to deliver pioneering research and innovation in Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the tax payer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust will set out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2020/21 these objectives included: • Recovery, restoration and improvement of clinical services • Implementing the ‘Always Improving’ strategy • Restoring a full research portfolio • Continuing our focus on staff wellbeing including the long-term effects of coronavirus (long COVID) • Working in partnership with the newly established integrated care system • Creating a sustainable financial infrastructure • Making our corporate infrastructure (digital, estate) fit for the future to support a leading university teaching hospital in the 21st century, including an estates masterplan. Performance against these objectives will be monitored and reported to the Trust’s board of directors on a quarterly basis. Principal risks to our strategy and objectives The board of directors has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2020/21 were that: • it would be unable to form effective partnerships that achieve networked care for patients; • it could not develop the estate in line with the ambitions set out in the strategy; • it would fail to restore and increase capacity following the COVID-19 pandemic to meet waiting times for elective care and cancer care needs; • it would fail to introduce and implement new technology for the transformation of care; • it would be unable to retain, recruit, develop and train a diverse and inclusive workforce necessary to meet the strategic goals; • it could not develop a sustainable model within the new financial regime that preserves quality care; • it would fail to provide vulnerable service users with timely and high quality and appropriate care; • it would not reach the ambition of outstanding compliance and quality standards; • it could not sufficiently engage with key stakeholders and system partners to support effective interventions and maintain the health of the local population; • it would be unable to respond to the needs of the NHS in order to deliver our strategy; • it would fail to capitalise on its relationship with the universities in Southampton and other health education providers in line with our strategy; • it would not develop innovative education and training approaches. 14 While the COVID-19 pandemic presented the Trust with new risks as it introduced more stringent infection control processes, stopped certain types of activity and responded quickly to care for large numbers of seriously ill patients who had tested positive for COVID-19, it also prompted innovation across a wide range of areas. However the ongoing impact of the pandemic on both our staff, patients who have had COVID-19 and patients who have waited longer than expected for treatment as a result, added to the risks facing the Trust. National targets for performance have not been amended as a result of the pandemic, although the national plan has focussed on the recovery of activity levels as the first stage in a restoration of elective services. Capacity – The initial and subsequent waves of the COVID-19 pandemic have led to increases in the waiting times for patients and the number of patients waiting more than 52 and 78 weeks has increased significantly. While the Trust was able to recover capacity quickly between waves of the pandemic, its ability to reduce the overall waiting list and the length of time patients are waiting for treatment remains one of the key risks for the Trust. This may be compounded by the reduction in the number of referrals from GPs during the pandemic, leading to a potential future increase in the number of patients being referred as people visit their GPs for the first time with more advanced disease. During the pandemic the Trust utilised the support available from the independent sector to continue cancer treatment and surgery for those patients at highest risk. It also increased the number of outpatient attendances which took place by telephone or video call. The Trust developed a clinical assurance framework during the year to better assess the risk of harm to patients as a result of delays in treatment and this has been utilised in decision-making around the allocation of resources to those areas where there is the greatest risk of potential harm to patients. In addition to opening additional capacity during 2020/21 (described in the Estates section below), the Trust also committed expenditure and commenced construction works in 2020/21 in order to be in a position to open an additional endoscopy room and four further operating theatres during 2021/22 and prepared plans for a significant expansion in ophthalmology outpatient capacity. These initiatives will contribute to improvements in elective waiting times that needed following the pandemic. Quality and compliance – The Trust continued to monitor the quality of care delivered throughout 2020/21. During the COVID-19 pandemic the primary focus became infection prevention and control, with the launch of a successful COVID ZERO campaign that saw the Trust reduce the transmission of the virus in hospital (nosocomial transmission). The Trust also achieved its annual target for reduction in Clostridium Difficile infections, however, there was one MRSA Bacteraemia during March 2021, the only such event in 2020/21. The Trust continued to develop its proactive patient safety culture during 2020/21 with changes to the way in which patient safety incidents are investigated and the approval of its Always Improving strategy, which will be launched in 2021. Reporting and investigation of incidents continued during 2020/21. Partnerships – During 2020/21, the Trust and its partners worked together very effectively to discharge patients safely and provide ongoing support to patients who had tested positive for COVID-19, to ensure patients requiring urgent cancer treatment and surgery were able to continue their treatment in the independent sector and to develop a COVID-19 saliva testing pilot with the University of Southampton and local authorities. Work to respond to the COVID-19 pandemic, however, meant that as a system we were unable to progress the Hampshire and Isle of Wight strategic plan delivery at the pace we would have wanted or had set out to achieve, particularly the development of networks. Nonetheless the application for Hampshire and Isle of Wight to become an integrated care system was approved with effect from 1 April 2021. 15 Existing networks continued to develop and improve. The Trust also became the Wessex Cancer Surgical Hub during 2020 as a result of a national initiative with the aim of maximising the number of patients receiving curative surgery. Both the Wessex Cancer Alliance and the Trust ended the year as the second highest performing among their respective peers for cancer treatment. Workforce – While additional staff were recruited to specifically assist the Trust during the pandemic, the Trust continued to recruit nurses from overseas during 2020/21 meaning that the number of vacancies has reduced compared to the position prior to the pandemic. Changes to recruitment processes were approved in 2020/21 to improve the fairness, transparency and quality of these. The Trust also continued to work with its staff networks and specific focus groups to increase diversity in leadership roles. While workforce capacity continues to be one of the biggest challenges faced by the Trust, during 2020/21 our main focus has been on supporting our staff to respond to the COVID-19 pandemic and providing both the tools and time to help staff recovery. We are incredibly proud of the way that staff responded to the pandemic and continue to recognise this in whatever ways we can, however, we also want to ensure that staff continue to be able to contribute to patient care at their best and want to stay and develop with the Trust. Technology was also used at levels not previously achieved to continue to deliver training to staff and enable staff to work from home where possible, ensuring a safer environment for patients and staff in the hospitals. Estate – The Trust continued to invest in and develop its estate during 2020/21 including the opening a new general intensive care unit (GICU), a new operating theatre and a new cancer care ward, built in just six months. These were part of £80 million of capital expenditure in 2020/21. The Trust has also established a programme to reduce backlog maintenance in addition to continuing to add to and improve the environment in which services are provided to patients and the working environment for staff. Innovation and technology – There have been exceptional levels of achievement in relation to COVID-19 related research activity, including in partnership with the universities. You can read more about these from page 167 of the quality report. The board of directors also supported the funding of an expansion of research and innovation activity to allow the continued delivery of the Trust’s ambitions to innovate and improve and transform its services. Sustainable financial model – The Trust achieved its forecast breakeven position in 2020/21. Income was more predictable in 2020/21 as block contract arrangements were put in place in response to the COVID-19 pandemic and ensured that costs were covered. The Trust continues to maintain a strong cash position and to implement improvements and efficiency savings, allowing it to continue to invest in its services. 16 Summary of performance COVID-19 bed occupancy UHS has experienced two distinct peaks in inpatient care for patients with COVID-19 infection, with smaller numbers of patients continuing to receive care outside these peak times. Bed occupancy reached a maximum of 173 in the first peak in April 2020, and 322 in the second peak in January 2021. All bed types Intensive care/higher care beds 17 Emergency access through our emergency and eye casualty departments Public concerns about safety, government restrictions on the activities people were able to do, and the efforts of community services contributed to significant reductions in the total number of patients who presented to our departments. All patients presenting to the emergency department Many changes were introduced within our departments in the course of the year to ensure that emergency assessment and treatment could be provided safely, including wearing of protective equipment by staff and patients, providing care in separate areas for patients suspected or known to have COVID-19, and using rapid laboratory tests to identify infection and confirm/exclude COVID-19 as a cause. Emergency access performance (measured as the percentage of patients discharged from emergency department care or admitted to a hospital bed within four hours of arrival to the department) improved significantly in 2020/21 compared to previous years. The national target of 95% was not achieved, however, the performance of our departments compared favourably with the average for acute trusts in England. 18 Emergency access four hour performance 19 Elective Waiting times Demand We saw a significant reduction in the number of elective referrals to hospital in the early part 2020/21, though they had returned close to pre-pandemic levels by the end of the year. It is likely that this pattern relates to a range of factors including reluctance from members of the public to attend healthcare facilities at that time, changes to the ways in which primary care was accessed, and efforts made within primary and community to avoid hospital referrals needing to be made. Accepted referrals The number of patients referred to hospital with suspected cancer also reduced during 2020/21; 7% fewer patients were seen across the year as a whole, though referrals returned to pre-pandemic levels or higher from July 2020 onwards. Patients seen following ‘Two week wait’ urgent referral for suspected cancer 20 Activity UHS hospital appointments, diagnostic tests and elective admissions were all significantly reduced during 2020/21 due to the impact of COVID-19. • During periods of higher bed occupancy with COVID-19 it was necessary to significantly reduce the number of elective admissions undertaken in order that additional staff could work in intensive care. Less clinically urgent and therefore longer waiting patients were primarily those affected. • Throughout the year, additional infection prevention measures have reduced the number of patients that can be seen in each session, particularly when higher risk ‘aerosol generating’ procedures are planned, but also as a result of additional PPE being worn or to enable greater distancing of patients attending outpatient departments. UHS was offered additional capacity at local independent sector hospitals and used this effectively to minimise these adverse impacts. Approximately 30% of outpatient appointments are now undertaken by telephone or video, helping to maintain the capacity for patient care whilst reducing the infection risk for those patients and helping to maintain distancing measures for those patients still attending our outpatient departments. The graphs below show 2020/21 activity levels as a percentage of those achieved in the previous year. Elective admissions (including daycase) 21 Outpatient attendances Performance The average waiting time for first outpatient appointments has remained close to nine weeks for the majority of the year. UHS has however experienced very significant deteriorations in the waiting times our patients experience for diagnostic tests to be undertaken and elective treatment to be provided. The reduced number of new patients referred to hospital early in 2020/21 has moderated the extent of the growth in the total numbers of patients waiting, and the greatest rate of growth has unfortunately been amongst those groups of patients already waiting longest. 22 Diagnostics Our performance measures for diagnostics report on a total of 15 different frequently used tests. The waiting list is approximately 50% bigger than it was before the pandemic and stable through the second half of the year. At the end of the year 28% of patients were waiting more than six weeks to receive their investigation compared to the national target of 1%. The tests with the largest numbers of longer waiting patients include non-obstetric ultrasound, MRI and endoscopies, and further recovery will be driven through a combination of recruitment, independent sector capacity and an additional endoscopy room which opened at the start of April 2021. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) Percentage of patients waiting over 6 weeks for a diagnostic test to be performed 23 Referral to Treatment Our waiting list from referral to treatment increased in size by 6% (2,220 patients) during 2020/21, rising when the recovery in referral numbers exceeded the recovery in clinical activity, the total increase in waiting list size would have been significantly higher had it not been for the significant reduction in the referrals received by the hospital especially during the early months of the pandemic. Looking forward, we anticipate referrals numbers returning to pre-pandemic levels, and being able to maintain the total size of our waiting list by delivering an equivalent number of treatments each month. Number of patients waiting between referral and commencement of a treatment for their condition The national target is that at least 92% of patients should be waiting for treatment no more than 18 weeks from their referral to hospital. Our performance against this measure is now 12% worse than one year ago, at 66%. Our performance continues to be typical of the major teaching hospital trusts that we benchmark with and the trend has been similar to that experienced across trusts in England. Percentage of patients waiting up to 18 weeks between referral and treatment 24 Unfortunately, the number of patients waiting significantly longer than the 18 week target has increased at a faster rate than the size of the waiting list as a whole. The graph below shows how the percentage of patients who have waited more 52 weeks increased. The number of patients who have waited more 52 weeks increased from 40 in March 2020 to 3,419 by March 2021 (of these 445 patients had waited more than 78 weeks). Such patients often require surgical treatment, particularly in the orthopaedic, ear nose and throat and oral surgery specialities. The impact on surgical care has been greater than that in outpatients during the pandemic, and it is also more challenging to increase capacity due to the need for additional operating theatres and a combination of different healthcare professionals to work within them. UHS opened an additional operating theatre in 2020/21, and has a further four theatres scheduled to open during 2021/22, which will make a significant contribution to our capacity to treat more patients. Unfortunately, the number of patients waiting significantly longer than the 18 week target is likely to continue to grow further in the short term, due to diagnostic investigations having been progressed less quickly than usual during the pandemic, the need to prioritise our increased treatment capacity according to the clinical urgency of conditions and because our scheduled capacity increases will not be completed before the autumn of 2021. Percentage of patients waiting more than 52 weeks, between referral and commencement of a treatment for their condition 25 Cancer Waiting Times UHS has been mostly successful in maintaining the timeliness of urgent services for patients with suspected cancer through the pandemic, and our performance has been amongst the best in both the south-east and nationally. UHS prioritised the theatre and intensive care capacity we were able to provide during the pandemic in order to meet the needs of those patients with the greatest clinical urgency, used capacity offered by independent sector hospitals to supplement that available within NHS, and operated a hub through which hospitals in Wessex were able to collaborate to continue critical cancer surgery during periods of peak COVID-19 demand. The national target is to provide the first definitive treatment to at least 85% of patients with cancer with 62 days of referral to hospital. Whilst UHS performance remained below this level in the majority of months, our performance has been significantly better than the national average, and has improved relative to other trusts. Treatment for Cancer within 62 days of an urgent GP referral to hospital 26 The national target is to provide the first definitive treatment to at least 96% of patients within 31 days of a decision to treat being made and agreed with the patients; both for the first and any subsequent treatments for cancer. UHS achieved this level on average across the year, and in the majority of months. The treatments provided are typically by means of surgery, chemotherapy/immunotherapy or radiotherapy. The most significant performance challenge this year has been in radiotherapy, where more sophisticated treatment plans improve patient outcomes but take longer to prepare, and there was also reduced treatment capacity whilst we replaced one of our ‘Linear Accelerator’ treatment machines with a new model. First definitive treatment for cancer within 31 days of a decision to treat Equality in service delivery Identifying and addressing health inequalities have been the central part of the Trust’s approach to improving the experience of care for our patients, families and carers. Over the past year, new initiatives have augmented progress on existing work to ensure there is appropriate support, due regard and recognition of those patients and their families and carers who are most at risk of poor experiences, outcomes and access to services. In 2020 we added two questions to our patient surveys, asking first if patients felt themselves to have a disability or require a reasonable adjustment, and, if yes, whether the Trust met this need. In 2020/21, the results were: TOTAL Had a disability / required a reasonable adjustment 27% Had this need met by the Trust (positive response) 95% This question was added to our major Friends and Family Test surveys as well as our local service-specific patient surveys. In June 2020 the Trust launched the sunflower lanyard scheme for hidden disabilities, participating in the national initiative to ensure that people whose disabilities are not visible are able to access further support and reasonable adjustments by means of a nationally recognised indicator (the sunflower). In 2020/21, 618 lanyards were issued with those needs recorded to ensure future reasonable adjustments are made for those individuals. 27 Carers have always been essential partners in the care that we provide, and having introduced a new post at the end of 2019 to focus solely on carer experience, this work has culminated in a Trust strategy for improving the involvement, support and experience carers have of our services. We have, over the past year, introduced carers cards, virtual peer support and carer-specific information about services while actively participating in local and regional work on carers. In January 2021 we realised our ambition of becoming an accredited ‘Veterans Aware’ hospital, with our submission of evidence being recognised as ‘strong’ and indicative of an organisation that has made great progress in helping to provide enhanced support for the armed forces community. Towards the end of 2019 we worked with the disability organisation AccessAble to produce accessibility guides for all of our services and estate. These online guides allow patients and visitors with disabilities to plan their journey and identify potential challenges to the environment. In 2020/21 our guides had 5,000 unique visits per month. One of our COVID-19 initiatives, a patient support hub, was set up in May 2020 to provide a single point of support for our patients who had been advised to shield. The service has grown and now offers support to patients and carers who are vulnerable, disabled or with additional needs. This includes coordinating community transport, arranging companions to assist with attending appointments, hosting a technology library to support those who are digitally excluded in accessing virtual appointments and information, and most recently receiving funding to pilot volunteer-led support for diabetes patients. Across the Trust, we continue to actively promote the importance of asking patients and carers about disabilities and reasonable adjustments, flagging needs on our patient administrative system to prompt our services to take proactive steps to ensure that any needs or adjustments are met on each and every visit. This has been of vital importance for meeting accessible information and communication needs. We are currently one of first trusts to pilot a new translation app that provides immediate interpretation into different languages, and we have worked closely with our communication support partners to ensure that where virtual appointments are needed, people with communication needs (BSL, foreign language) are supported to access care virtually. Our specialist nursing liaison teams continued to support access to services throughout the pandemic, ensuring that patients with dementia, with learning disabilities and autism, were supported to attend hospital where necessary. Further information about the Trust’s work in relation to equality, diversity and inclusion can be found on page 69 and pages 106 and 160 in the quality report. Going concern After making enquiries, the directors have a reasonable expectation that the services provided by the Trust will continue to be provided by the public sector for the foreseeable future. For this reason, the directors have adopted the going concern basis in preparing the accounts, following the definition of going concern in the public sector adopted by HM Treasury’s Financial Reporting Manual. David French Chief Executive Officer 28 June 2021 28 Accountability report Directors’ report Board of directors The board of directors is usually made up of six executive directors and seven non-executive directors, including the chair. Since 1 January 2021 the number of non-executive directors has been reduced by one as Jane Bailey’s reappointment as a non-executive director was deferred to allow her to lead the Hampshire and Isle of Wight saliva mass testing programme. Jane is expected to return to the board of directors in her non-executive director role by 1 July 2021. Paragraph B.1.2 of the NHS foundation trust code of governance provides that at least half the board of directors, excluding the chair, should comprise non-executive directors determined by the board to be independent. Pending the reappointment of Jane Bailey as a non-executive director, the Trust has been operating with one fewer non-executive directors than is required by the Trust’s constitution and the Trust has been non-compliant with this paragraph of the code. During this period the provisions of the Trust’s constitution that a quorum for meetings of the board of directors requires at least one non-executive director and one executive director to be present and for the chair to have a second and casting vote in the case of an equal vote continued to apply. The board of directors has given careful consideration to the range of skills and experience it requires to run the Trust. Together the members of the board of directors bring a wide range of skills and experience to the Trust, such that the Board achieves balance and completeness at the highest level. The chair was determined to be independent on his appointment and the other non-executive directors have been determined to be independent in both character and judgement. This included specific consideration of Jane Bailey’s continued independence following her role leading the Hampshire and Isle of Wight saliva mass testing programme. The chair, executive directors and non-executive directors have declared any business interests that they have. Each director has declared their interests at public meetings of the board of directors. The register of interests is available on the Trust’s website. 30 The current members of the board of directors are: Non-executive directors Peter Hollins Chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, in 1992 he was appointed as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, before returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non-executive director in 2010, became senior independent director and deputy chairman of UHS in 2014 and was appointed chair in April 2016. Trust roles: • Chair of remuneration and appointment committee • Chair of governors’ nomination committee Jane Bailey Non-executive director In 1985, Jane joined the pharmaceutical company Glaxo as a management trainee, having graduated from London University with a degree in environmental science and pharmacology. Here she rose to senior commercial vice-president, gaining experience of a broad range of disease areas across different regions of the world. She specialised in leading global research and development teams in the formation of strategies to bring new medicines to patients. She also worked to ensure that the medicines developed were supported by robust evidence demonstrating their clinical and cost-effectiveness. In delivering this she gained extensive experience of leading large diverse teams across a complex global organisation. For five years, Jane ran her own strategy development consultancy, working across a breadth of healthcare organisations. In 2017 Jane gained an MSc in public health, with distinction, at King’s College, London University. Her studies focused on how to ensure the public are engaged in development of healthcare services and how social theories can help inform effective disease prevention and management. Jane is a director of Wessex NHS Procurement Limited, a joint venture between the Trust and Hampshire Hospitals NHS Foundation Trust and a director of Healthwatch Portsmouth. Trust roles: • Deputy chair and senior independent director • Chair of finance and investment committee • Audit and risk committee member • Charitable funds committee member • People and organisational development committee member • Remuneration and appointment committee member • Wellbeing Guardian 31 Non-executive directors Dave Bennett Non-executive director Dave graduated in chemistry from the University of Southampton before entering management consulting, becoming a partner in Accenture’s strategy practice. In 2003 he joined Exel Logistics (later acquired by DHL), managing the company’s healthcare business across Europe and the Middle East. During this time, he established NHS Supply Chain, a UK organisation responsible for procuring and delivering medical consumables for the NHS in England, as well as sourcing capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016, where he chaired the Trust’s quality committee. Dave is a non-executive director at the Faculty of Leadership and Medical Management and a director of Royal College of General Practitioners (RCGP) Enterprises Ltd and RCGP Conferences Ltd. Trust roles: • Chair of charitable funds committee • Chair of finance and investment committee (from 1 January 2021) • Audit and risk committee member (from 9 February 2021) • Quality committee member • Remuneration and appointment committee member • Chair of Trust’s organ donation committee 32 Non-executive directors Cyrus Cooper Non-executive director Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He is also vice-dean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. He is president of the International Osteoporosis Foundation, chair of the BHF Project Grants Committee, an emeritus NIHR senior investigator, a director of The Rank Prize Funds and associate editor of Osteoporosis International. He has previously served as chairman of the Scientific Advisors Committee (International Osteoporosis Foundation), the MRC Population Health Sciences Research Network and the National Osteoporosis Society of Great Britain. He has also been president of the Bone Research Society of Great Britain and has worked on numerous Department of Health, European Community and World Health Organisation committees and working groups. Cyrus has published extensively on osteoporosis and rheumatic disorders and pioneered clinical studies on the developmental origins of peak bone mass. In 2015, he was awarded an OBE for services to medical research. Trust roles: • Quality committee member • Remunerati
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Cemiplimab

Description: Chemotherapy Protocol SKIN CANCER Cemiplimab (350mg) Regimen  Skin – Cemiplimab (350mg) Indication  Metastatic or locally advanced cutaneous squamous cell carcinoma in patients who are not candidates for curative surgery or curative radiation. Toxicity Drug Cemiplimab Adverse Effect Immune-related reactions including pneumonitis, colitis, hepatitis, hypothyroidism and hyperthyroidism. Fatigue, rash, pruritis, muscular skeletal pain, arthralgia, central nervous system disorders and infusion related reactions The adverse effects listed are not exhaustive. Please refer to the relevant Summary of Product Characteristics for full details. Monitoring  FBC, LFTs and U&Es prior to each cycle for 8 cycles then every 12 weeks or as clinically indicated  Thyroid function tests at baseline then every 6 weeks or as clinically indicated  Blood glucose monitoring every 6 weeks or as clinically indicated Dose Modifications The dose modifications listed are for haematological, liver and renal function and some drug specific toxicities only. Dose adjustments may be necessary for other toxicities as well. The dose modifications listed are for haematological, liver and renal function and some drug specific toxicities. Cemiplimub belongs to the immunotherapy class of cancer treatments. Autoimmune toxicities are most frequently noted and can be life threatening. If autoimmune toxicities occur delaying treatment should be considered while investigations or treatments are organised. Some, but not all, toxicities mandate cessation of treatment. Please seek guidance from relevant site specific specialist teams or oncologists / haematologists with experience of prescribing these agents. Clinicians should be aware that the current funding approval precludes further treatment after an interruption of 12 weeks or longer; this situation may change. Refer to the latest version of the European Society of Medical Oncology guidelines; Management of toxicities from immunotherapy: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up(1). Version 1 (July 2019) Page 1 of 9 Skin –Cemiplimab (350mg) Haematological There is no requirement for dose modification or treatment interruption due to haematological toxicity. Consider blood transfusion or erythropoietin if patient symptomatic of anaemia or has haemoglobin of less than 8g/dL (80g/L). Hepatic Impairment There is no requirement for dose modification of cemiplimab in patients with mild hepatic impairment prior to starting therapy. Cemiplimab has not been studied in patients with moderate or severe hepatic impairment prior to starting therapy. There are insufficient data in patients with moderate or severe hepatic impairment for dosing recommendations. For patients on cemiplimab who develop immune related hepatitis see below for the treatment of immune-related adverse reactions Renal Impairment No dose adjustment of cemiplimab is recommended for patients with renal impairment prior to starting therapy. There are limited data for cemiplimab in patients with severe renal impairment (creatinine clearance less than <30 ml/min) prior to starting therapy. For patients on cemiplimab who develop immune related nephritis see below for the treatment of immune-related adverse reactions Other Dose reductions or interruptions in therapy are not necessary for those toxicities that are considered unlikely to be serious or life threatening. For example, alopecia, altered taste or nail changes. Cemiplimab is associated with inflammatory adverse reactions resulting from increased or excessive immune activity, likely to be related to its pharmacology. Immune-related adverse reactions, which can be severe or life-threatening, may involve the gastrointestinal, liver, skin, nervous, endocrine, or other organ systems. Most occur during treatment, however, onset months after the last dose have been reported. Unless an alternate aetiology has been identified, diarrhoea, increased stool frequency, bloody stool, LFT elevations, rash and endocrinopathy must be considered inflammatory and cemiplimab-related. Early diagnosis and appropriate management are essential to minimise life-threatening complications. Cemiplimab should be permanently discontinued for: any NCI-CTC grade 3 or 4 pneumonitis or hepatitis; any other life threatening NCI-CTC grade 4 reaction (including colitis and renal impairment); any recurrence of a severe or NCI-CTC grade 3 reaction; any persistent NCI-CTC grade 2 or 3 treatment-related adverse Version 1 (July 2019) Page 2 of 9 Skin –Cemiplimab (350mg) reaction that does not recover to grade 1 or resolve within 12 weeks after the last dose. Cemiplimab should be withheld for: any NCI-CTC grade 2 pneumonitis or hepatitis; any grade 2 or 3 colitis or renal impairment; any other severe or grade 3 treatmentrelated adverse reaction. Do not resume cemiplimab if the patient is still receiving immunosuppressive doses of corticosteroids or other immunosuppressive therapy. Treatment with cemiplimab should be permanently discontinued for grade 2 or 3 immune-related adverse reactions that persist in spite of treatment modifications or a reduction of corticosteroid dose to 10mg prednisolone, or equivalent, cannot be achieved. Immune-related adverse reaction Severity Treatment modification Immune-related pneumonitis (see text below) Grade 2 pneumonitis Withhold until symptoms resolve, radiographic abnormalities improve, and management with corticosteroids is complete Grade 3 or 4 pneumonitis Permanently discontinue Immune- related colitis (see text below) Grade 2 or 3 diarrhoea or colitis Withhold until symptoms resolve and management with corticosteroids, if needed, is complete Grade 4 diarrhoea or colitis Permanently discontinue Immune-related hepatitis Grade 2 elevation in aspartate aminotransferase (AST), alanine aminotransferase (ALT), or total bilirubin Withhold until laboratory values return to baseline and management with corticosteroids, if needed, is complete Grade 3 or 4 elevation in AST, ALT, or Permanently discontinue total bilirubin Immune-related Grade 2 or 3 creatinine elevation nephritis and renal dysfunction Withhold until creatinine returns to baseline and management with corticosteroids is complete Grade 4 creatinine elevation Permanently discontinue Immune-related endocrinopathies (see text below) Symptomatic endocrinopathies (including Withhold until symptoms resolve hypothyroidism, hyperthyroidism, and management with hypophysitis, adrenal insufficiency and corticosteroids (if needed for diabetes) symptoms of acute inflammation) is complete. Cemiplimab should be continued in the presence of hormone replacement therapy as long as no symptoms are present Immune-related rash Grade 3 rash Withhold dose until symptoms resolve and management with corticosteroids is complete Grade 4 rash Permanently discontinue Version 1 (July 2019) Page 3 of 9 Skin –Cemiplimab (350mg) Endocrine Cemiplimab can cause inflammation of the endocrine system organs, specifically hypophysitis, hypopituitarism, adrenal insufficiency, and hypothyroidism. This may present with nonspecific symptoms resembling other causes such as brain metastasis or underlying disease. Isolated hypothyroidism can be managed with replacement therapy, without treatment interruption or corticosteroids. If there are any signs of adrenal crisis such as severe dehydration, hypotension, or shock, immediate administration of intravenous corticosteroids with mineralocorticoid activity is recommended, the patient must be evaluated for presence of sepsis or infections. If there are signs of adrenal insufficiency but the patient is not in crisis, further investigations should be considered including laboratory and imaging assessment. Evaluation of laboratory results to assess endocrine function may be performed before corticosteroid therapy is initiated. If pituitary imaging or laboratory tests of endocrine function are abnormal, a short course of high-dose corticosteroid therapy is recommended to treat the gland inflammation. The scheduled dose of cemiplimab should be omitted. It is currently unknown if the corticosteroid treatment reverses the gland dysfunction. Appropriate hormone replacement should also be initiated. Long-term hormone replacement therapy may be necessary. Once symptoms or laboratory abnormalities are controlled and overall patient improvement is evident, treatment with cemiplimab may be resumed and initiation of corticosteroid taper should be based on clinical judgment. Hypophysitis can present as a diffuse, heterogenous enlargement of the pituitary on a brain MRI but can be completely normal. When hypophysitis with pituitary dysfunction is suspected, blood tests including thyroid stimulating hormone (TSH), free T4, adrenocorticotropic stimulating hormone (ACTH), cortisol, luteinising hormone (LH), and follicle-stimulating hormone (FSH) should be obtained in women, and the first four plus testosterone in men. Typically the anterior pituitary axis is involved, affecting thyroid, gonadal, and adrenal function, but isolated axis dysfunction can be seen. Hypophysitis will cause low free T4 as well as TSH. Hypophysitis with clinically significant adrenal insufficiency and hypotension, dehydration, and electrolyte abnormalities such as hyponatremia and hyperkalemia constitutes adrenal crisis. Hospitalization and intravenous steroids with mineralocorticoid activity, such as methylprednisolone, should be initiated while waiting for laboratory results. Cases should be jointly managed with an endocrinologist. Infection and sepsis should be ruled out with appropriate cultures and imaging. Prednisolone 1mg/kg by mouth should be administered if patients are clinically stable. Steroids can usually be tapered over 30 days to achieve physiologic replacement levels. Thyroid hormone and/or testosterone replacement therapy may not be permanent, as the need for those hormones may wane over months in some patients. Cortisone replacement may also not be permanent in a modest portion of patients. Gastrointestinal Gastro-intestinal immune reactions include diarrhoea, increased frequency of bowel movements, abdominal pain or haematochezia, with or without fever. Diarrhoea or Version 1 (July 2019) Page 4 of 9 Skin –Cemiplimab (350mg) colitis occurring after initiation of cemiplimab must be promptly evaluated to exclude infectious or other alternate causes. Immune-related colitis is often associated with evidence of mucosal inflammation, with or without ulcerations and lymphocytic and neutrophilic infiltration. NCI-CTC grade 1 diarrhoea or suspected mild colitis may continue on cemiplimab. Symptomatic treatment and close monitoring are advised. For a NCI-CTC grade 2 - 3 diarrhoea or colitis withhold the cemiplimab and administer corticosteroids. Upon improvement to NCI-CTC grade 1 begin to taper the corticosteroid over a period of one month. The cemiplimab may be re-started when the diarrhoea or colitis remains at NCI-CTC grade 1 following corticosteroid taper. The cemiplimab should be permanently discontinued when the diarrhoea or colitis does not improve to at least NCI-CTC grade 1 within 12 weeks of the last dose, the corticosteroid dose cannot be reduced to 10mg or less of prednisolone or equivalent per day within 12 weeks or in the case of a recurrent NCI-CTC grade 3 reaction. For Grade 4 diarrhoea or colitis, cemiplimab must be permanently discontinued, and corticosteroid treatment initiated. Lung Interstitial lung disease including pneumonitis and acute interstitial pneumonitis are associated with cemiplimab. For NCI-CTC grade 1 events (asymptomatic with radiographic findings only) then the cemiplimab may be continued with close monitoring. Radiologic findings should be followed on serial imaging studies and consideration given to pulmonary consultation and/or bronchoscopy, if clinically indicated. For NCI-CTC grade 2 events withhold the cemiplimab and consider pulmonary consultation with bronchoscopy and biopsy/bronchoalveolar lavage (BAL) and pulmonary function tests. Treat with systemic corticosteroids at a dose of 1 to 2 mg/kg/day prednisone or equivalent. When symptoms improve to NCI-CTC grade 1 or less, steroid taper should be started and continued over no less than 4 weeks. Treatment with cemiplimab may be resumed if the event improves to NCI-CTC grade 0 or 1 within 12 weeks and corticosteroids have been reduced to the equivalent of prednisolone 10 mg oral daily or less. Repeat chest imaging monthly as clinically indicated. Should a second episode of pneumonitis occur then discontinue cemiplimab. For NCI-CTC grade 3 or 4 events discontinue cemiplimab and consider pulmonary function tests and seek advice from a lung specialist. A bronchoscopy with biopsy and / or BAL should be considered. Treatment involves corticosteroid therapy such as intravenous methylprednisolone 125mg. When symptoms improve to NCI-CTC grade 1 or less, a high dose oral steroid such as prednisone 1 to 2 mg/kg once per day can be considered. A reducing schedule should be considered over a period of at least four weeks. If intravenous corticosteroids followed by high dose oral corticosteroids do not reduce initial symptoms within 48 to 72 hours, treat with infliximab at 5 mg/kg once every 2 weeks. Discontinue infliximab upon symptom relief and initiate a prolonged steroid taper over 45 to 60 days. If symptoms worsen during steroid reduction, initiate a re-tapering of steroids starting at a higher dose followed by a more prolonged taper and administer infliximab. Version 1 (July 2019) Page 5 of 9 Skin –Cemiplimab (350mg) Regimen 21 day cycle continued until disease progression or development of unacceptable toxicity or for up to 24 months, whichever is sooner. (35 cycles will be set in ARIA) Drug Cemiplimab Dose 350mg Days 1 Route Intravenous infusion in 100ml sodium chloride 0.9% over 30 minutes Administration Information  Cemiplimab must be administered via a 0.2 to 5 micron an in-line or add-on filter.  The final concentration of cemiplimab should be between 1 and 20mg/ml. Other Additional Therapy  No antiemetics are required  As required for the treatment of infusion related reactions; - chlorphenamine 10mg intravenous - hydrocortisone 100mg intravenous - paracetamol 1000mg oral Additional Information  Patients receiving cemiplimab must be issued with a Patient Alert Card  No pharmacokinetic drug-drug interaction studies have been conducted with cemiplimab.  The use of systemic corticosteroids or immunosuppressants before starting cemiplimab, except for physiological doses of systemic corticosteroid (less than or equal to 10 mg/day prednisone or equivalent), should be avoided because of their potential interference with the pharmacodynamic activity and efficacy of cemiplimab. However, systemic corticosteroids or other immunosuppressants can be used after starting cemiplimab to treat immunerelated adverse reactions. Version 1 (July 2019) Page 6 of 9 Skin –Cemiplimab (350mg) Coding  Procurement – X70.8  Delivery – X72.9 References 1. Haanen J, Carbonnel F, Robert C, Kerr K.M , Peters S, Larkin J, Jordan J on behalf of the ESMO Guidelines Committee. Management of toxicities from immunotherapy. ESMO clinical practice guidelines for diagnosis, treatment and follow up. Ann Oncol 2017; 28 (suppl 4): 119-142. 2.Midgen MR, Rischin D, Schmults CD et al. PD-1 Blockade with Cemiplimab in Advanced Cutaneous SquamousCell Carcinoma. N Engl J Med 2018; 379:341-351 Version 1 (July 2019) Page 7 of 9 Skin –Cemiplimab (350mg) REGIMEN SUMMARY Cemiplimab (350mg) Day One 1. Cemiplimab 350mg in 100ml sodium chloride 0.9% over 30minutes Administration Instructions Administer using a 0.2-5micron in-lineor add on filter 2. Chlorphenamine 10mg intravenous when required for infusion related reactions 3. Hydrocortisone 100mg intravenous when required for infusion related reactions 4. Paracetamol 1000mg oral when required for infusion related reactions Version 1 (July 2019) Page 8 of 9 Skin –Cemiplimab (350mg) DOCUMENT CONTROL Version Date Amendment Written By Approved By 1 July 2019 None Rebecca Wills Pharmacist Dr Deborah Wright Pharmacist Dr Sarah Ellis Consultant Medical Oncologist This chemotherapy protocol has been developed as part of the chemotherapy electronic prescribing project. This was and remains a collaborative project that originated from the former CSCCN. These documents have been approved on behalf of the following Trusts; Hampshire Hospitals NHS Foundation Trust NHS Isle of Wight Portsmouth Hospitals NHS Trust Salisbury NHS Foundation Trust University Hospital Southampton NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust All actions have been taken to ensure these protocols are correct. However, no responsibility can be taken for errors that occur as a result of following these guidelines. Version 1 (July 2019) Page 9 of 9 Skin –Cemiplimab (350mg)
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Papers Council of Governors 20 July 2022

Description: Agenda attachments 1 CoG Agenda - 20.07.2022.docx Date Time Location Chair Agenda Council of Governors 20/07/2022 14:00 - 15:30 Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:02 3 Minutes of Previous Meeting 14:03 Approve the minutes of the previous meeting held on 27 April 2022 4 Matters Arising/Summary of Agreed Actions 14:04 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:06 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Gail Byrne, Chief Nursing Officer 5.2 Strategic Objectives (Oral) 14:26 Review and feedback on the Strategic Objectives Sponsor: David French, Chief Executive Officer Attendee: Christine McGrath, Director of Strategy and Partnerships 6 Governance 6.1 Non-Executive Director Reappointment and Appointment of Deputy Chair 14:41 • Approve Tim Peachey’s reappointment as a non-executive director for a second three year term commencing on 1 October 2022 on the same terms and conditions as his current appointment • Approve the recommendation to defer the appointment of a deputy chair to the meeting on 19 October 2022 following a recommendation made by the newly appointed chair Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 6.2 Amendments to the Constitution 14:51 Approve the proposed amendments to the Trust’s constitution Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 6.3 Appointment of Lead Governor 14:56 Note the proposal to appoint the Lead Governor Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:01 Receive the report Sponsor: David French, Chief Executive Officer Attendee: Karen Burwell, Communications and Marketing Manager 7.2 Feedback from Governors' Nomination Committee 15:06 Chair: Jenni Douglas-Todd, Trust Chair 7.3 Feedback from Strategy and Finance Working Group 15:09 Chair: Tim Waldron 7.4 Feedback from Patient and Staff Experience Working Group 15:12 Chair: Forkanul Quader 7.5 Feedback from Membership and Engagement Working Group 15:15 Chair: Bob Purkiss 8 Review of Meeting 15:18 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any other business 15:23 Raise any relevant or urgent matters that are not on the agenda 10 Date of next meeting: 19 October 2022 15:28 Note the date of the next meeting 11 Resolution regarding the press, public and others 15:29 Agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Council of Governors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 3 Minutes of Previous Meeting 1 3 COG Minutes Draft - 27.04.2022 final.pdf Minutes - Council of Governors (CoG) Date Time Location Chair Present In attendance Apologies 27 April 2022 14.00-16.00 Microsoft Teams Jane Bailey, Interim Chair Jane Bailey, Interim Chair Dr Diane Bray, Appointed, Solent University Dr Nigel Dickson, Elected, New Forest, Eastleigh and Test Valley Helen Eggleton, Appointed, NHS Hampshire, Southampton and Isle of Wight CCG Harry Hellier, Elected, New Forest, Eastleigh and Test Valley Kelly Lloyd, Elected, Health Professional and Health Scientist Staff Councillor Alexis McEvoy, Appointed, Hampshire County Council Robert Purkiss, Elected, Rest of England and Wales (until item 6.4) Forkanul Quader, Elected, Southampton City Catherine Rushworth, Elected, Isle of Wight Councillor Rob Stead, Appointed, Southampton City Council (until item 6.5) Werner Struss, Elected, Medical Practitioners and Dental Staff Amanda Turner, Elected, Non-Clinical and Support Staff Quintin van Wyk, Elected, Rest of England and Wales Sam Dolton, Events and Membership Officer Karen Flaherty, Associate Director of Corporate Affairs Ian Howard, Chief Financial Officer (for items 5.1 and 5.2) David French, Chief Executive Officer (for item 5.3) Tim Peachey, Non-Executive Director (NED) Karen Russell, Council of Governors’ Business Manager Asa Thorpe, Associate Director – Commercial (for item 5.2) Theresa Airiemiokhale, Elected, Southampton City Katherine Barbour, Elected, Southampton City Professor Mandy Fader, Appointed, University of Southampton Tim Waldron, Elected, Southampton City JB DB ND HE HH KL AM RP FQ CR RS WS AT QvW SD KF IH DAF TP KR ATh TA KBa MF TW 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting and, in particular, WS who was attending a meeting of the CoG for the first time since becoming a governor. 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 3 Minutes of Previous Meeting The minutes of the meeting held on 26 January 2022 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions The updates on the actions in the paper were noted. The review of the CoG’s 1 composition had been considered by the CoG Membership and Engagement Working Group at its most recent meeting and a progress update would be provided later in the meeting. 5 Strategy, Quality and Performance 5.1 Operational Plan 2022/23 IH, who was attending the meeting to present this item, advised that the operational plan for 2022/23 had also been presented to the CoG Strategy and Finance Working Group at its meeting on 21 April 2022. The purpose of the paper was to inform the CoG about aspects of the Trust’s operating environment and plan for 2022/23. The following areas were summarised: • the Trust’s income for 2022/23 was broadly level with 2021/22 and the expectation was that 104% of the 2019/20 levels of elective activity would be delivered with this level of funding, through increased efficiency improvement valued at £33 million; • there were planned operating deficits across the NHS and the Trust’s deficit of £19.5 million was attributable to factors outside of its control, including costs associated with COVID-19, increased energy prices and general inflationary pressures; and • there were plans for continued recruitment and retention to increase employed staff by a further 478 full-time equivalent staff, to be funded through planned reductions in the use of bank and agency staff hours. In response to questions raised IH confirmed: • the Trust’s specialities with the patients waiting longest (over 18 months and two years) were: o trauma and orthopaedics, where procedures were of lower clinical priority and had been deferred for that reason; and o ear, nose and throat, where activity had reduced because of infection prevention and control measures related to aerosol generating procedures; and • although recruitment to fill vacancies was continuing there was no funding for new posts, however, additional investment in staffing would be required in 2023/24 and 2024/25 to meet the expected increase in elective activity to reduce waiting lists further. 5.2 Non-NHS Activity This item had also been discussed by the CoG Strategy and Finance Working Group at its meeting on 21 April 2022. The Trust’s private patient income for 2021/22 was forecast to be approximately £6.4 million, which represented just under 0.7% of the Trust’s overall income. The growth in activity had been due to more complex patients being treated, whilst maintaining the prioritisation of clinically urgent procedures in the context of the unprecedented pressure on core NHS services. Private patient activity was expected to remain at similar levels for at least the next six months. The income from non-NHS activity, including private patient activity, was reinvested into NHS services and to support further innovation and activity. Non-NHS income was also derived from the following: • the commercialisation of Trust-derived intellectual property with an expected forecast of at least £140,000 in 2022/23; • the co-development of innovative medical technology, for which the income forecast was £150,000 for 2022/23; and • advertising income from the electronic screens located in patient areas 2 around the hospitals. Details of a range of the innovative therapies, treatments and projects being developed by the Trust were shared with governors. Decisions: • The CoG confirmed that it was satisfied that the Trust’s non-NHS activity would not significantly interfere with its principal purpose, which was to provide goods and services for the health service in England, or the performance of its other functions. • The CoG authorised the Trust Chair to inform the board of directors (Board) of its decision. 5.3 Chief Executive Officer’s Performance Report DAF joined the meeting to present the performance report and provided an update since the period of December 2021 to February 2022 covered by the report. He highlighted that: • March and April 2022 had been very challenging for the NHS nationally due to the high levels of COVID-19 among patients in hospital for other reasons, and in norovirus reflecting the prevalence of these viruses in the community; • the Trust’s staff absence rates had increased to 6% at times from approximately 3% normally due to staff having COVID-19 or self-isolating; • there were consistently 180 patients in the hospitals who were medically optimised for discharge (MOFD), however, continuing levels of staff absence in community and domiciliary care services and in care homes were leading to delays in discharge for patients needing further support following discharge or with longer-term care needs; • attendances in the emergency department were increasingly high and the Trust’s emergency access performance had been impacted negatively by the number of attendances, including the Trust’s approach to ambulance handovers, which resulted in fewer ambulances queuing but more patients in the department; • the volume of non-elective urgent activity and the number of patients MOFD had regrettably led to the cancellation of elective activity, which had both a practical and emotional impact on those patients whose surgery was delayed; • cases of COVID-19 and norovirus in the Trust had dropped substantially in the previous two weeks and the focus had moved to delivering the Trust’s programme of elective activity; • the number of patients waiting over 104 weeks had reduced to five by the end of March 2022 and the Trust was confident that this would be zero by July 2022; • the Trust had increased both physical and workforce capacity through investment over the previous few years, however there was still insufficient capacity, and this was being addressed through the creation of clinical networks with partners and improvement programmes in theatres, outpatients and patient flow through the hospitals; and • recruitment and retention of staff was more difficult in an increasingly competitive employment market, however, in the NHS staff survey 2021, the Trust had scored highly among staff recommending it to care for family and friends (fifth in its peer group) and recommending it as a place to work (seventh in its peer group). In response to a question from CR, DAF confirmed that the Trust did offer incentive payments to staff who worked additional shifts, however, substantive recruitment 3 was the solution to ensure a good work life balance and overall wellbeing for staff. In response to a query from FQ regarding the expected performance of the Trust in six months’ time, DAF agreed it was difficult to predict however, he hoped that there would significantly fewer cases of COVID-19 and elective activity would return to levels achieve previously and the Trust could deliver comparative performance in the top quartile. The next few years would be very difficult for the NHS generally as it reduced waiting times and the number of patients waiting. While the Trust’s plans to reduce waiting lists were achievable, capacity would continue to be an issue for the Trust. The number of patients who were MOFD would have a bearing on this so the Trust would continue to work closely with health and social care partners to facilitate the timely discharge of patients. The plans to open a new elective hub at Winchester Hospital within the next 18 months would also provide additional capacity and clinical, managerial and finance teams at the trusts involved were committed to making this work. In response to a question from RP, DAF advised that the maternity friends and family test score had improved substantially in January and February 2022 as a result of an improvement plan put in place in the antenatal ward, and progress had been closely monitored by the Board. The response time for complaints had been increased from 35 to 55 days to recognise the demands upon clinical staff during the latest wave of the COVID-19 pandemic. There had also been a number of changes to personnel within the patient advice and liaison service (PALS) as staff had moved into other roles in the Trust. 5.4 Draft Quality Report and Annual Report Timetable NHS England and NHS Improvement (NHSE/I) had published the timetable for the 2021/22 annual report and accounts and associated guidance. While this had removed the requirements to produce a separate quality report, the quality accounts requirements set out in The National Health Service (Quality Accounts) Regulations 2010 still applied requiring trusts to produce quality accounts, including circulation of the quality accounts to commissioners, local authorities, local Healthwatch and the CoG for comment by the end of April 2022. The Trust had taken the decision to produce the annual report and accounts and the quality accounts on the same timetable as a single document by the submission deadline of 22 June 2022. However, due to the additional work required to complete the value for money external audit, the quality accounts were to be published as a separate document by 30 June 2022. The annual report and accounts would be published after they had been laid before Parliament, which was expected to occur at the beginning of September 2022. The timing of the meeting of the CoG at which the final annual report and accounts (including the quality accounts) and the external auditors’ report were to be presented would be later than usual to allow for these to be laid before Parliament as this would normally take place in July. An update would be provided to the CoG in a closed session of its meeting in July 2022 to mitigate the impact of this delay. The date of the annual members’ meeting would be finalised at a later date to ensure that the annual report and accounts were laid before Parliament before the annual members’ meeting took place. Governors had been invited to provide comments or feedback on the draft quality accounts for 2021/22 by 29 April 2022 and the formal response to the consultation from the CoG would be co-ordinated by RP as Lead Governor. 4 6 Governance 6.1 Non-Executive Director Reappointment The first three year term of office as a NED for Dave Bennett was to come to an end on 14 July 2022. NEDs were eligible for reappointment for a second three year term subject to reappointment by the CoG. When considering the reappointment of a NED, the CoG should consider: • the outcome of the NED’s appraisals since appointment; • their other commitments and the time available for the role; and • independence. The most recent appraisal of Dave Bennett was carried out in February 2022. Following appraisal, the then Chair, Peter Hollins, confirmed that Dave Bennett’s performance as a NED continued to be effective and demonstrated his commitment to the role and that he would have no hesitation in recommending Dave Bennett for reappointment to the role. Since his original appointment, Dave had ceased his commercial consultancy business, Davox Consulting Ltd, and had been appointed to the following NED/trustee roles: • Chairman, Royal College of General Practitioners (RCGP) Enterprises Ltd • Chairman, RCGP Conferences Ltd • NED, Faculty of Leadership and Medical Management (FMLM) • Director, FMLM Applied Ltd • Director/Trustee and Chair, YMCA Fairthorne Group. Dave had indicated his willingness to be reappointed for a further three year term and confirmed that he continued to have the time to commit to the role. The Governors’ Nomination Committee (GNC) had met on 26 April 2022 and had agreed to recommend that the CoG approve the reappointment without any need for process of open competition. Decision: The CoG approved Dave Bennett’s reappointment as a NED for a second three year term commencing on 15 July 2022 on the same terms and conditions as his current appointment. 6.2 Review Terms of Reference – Council of Governors and Working Groups The terms of reference for the Council of Governors and its working groups should be reviewed regularly, and at least once annually, to ensure that these reflected the purpose and activities of the CoG and each of the working groups. The terms of reference for the GNC were reviewed by the CoG at its meeting in October 2021 and so were not presented for review at this meeting. The terms of reference for the CoG’s working groups had been reviewed by the relevant working group prior to submission to the CoG. Minor changes were proposed to reflect changes to practice and strategies since the terms of reference were last reviewed. Decision: The CoG approved the revised terms of reference for the: • CoG; • CoG Membership and Engagement Working Group; • CoG Patient and Staff Experience Working Group; and • CoG Strategy and Finance Working Group 5 6.3 Council of Governors’ Election 2022 A number of vacancies within the CoG would arise on 1 October 2022 as current governors reached the end of their terms of office, following agreement of the CoG to fill existing vacancies at the scheduled election in 2022 and as a result of proposed changes to the composition of the CoG taking effect from 1 October 2022. Elections would take place in the following areas of the public constituency and classes of the staff constituency: • Isle of Wight - one vacancy; • Southampton City - five vacancies; • New Forest, Eastleigh and Test Valley - three vacancies for a term of three years and one vacancy with a remaining term of office of one year; • Rest of England and Wales - one vacancy with a remaining term of office of two years; • Non-clinical and support staff class - one vacancy; • Nursing and Midwifery staff class - one vacancy; As a result of the proposed changes to the composition of the CoG taking effect from 1 October 2022, a vacancy that would have arisen in the Rest of England and Wales public constituency would not be filled as the number of governors representing this constituency was to be reduced by one. The timetable for the elections had been prepared in accordance with the guidance specified in the model election rules. The elections would be conducted by an independent election service provider acting as the returning officer on behalf of the Trust. Four election service providers had been invited to provide a quote and three quotes had been received. A meeting had been held with each of the three providers on 27 April 2022 and a decision on which to appoint would be made by 29 April 2022. 6.4 Council of Governors’ Expenses Reimbursement Protocol The CoG expenses reimbursement protocol had been updated and reformatted and additional clarification had been added in a number of areas not previously included in the protocol. The protocol was required to approved by the Board in accordance with the Trust’s constitution. Clarification for governors was requested in relation to: • how costs for printing would be reimbursed; and • whether governors who had been issued with permits for staff car parks could continue to use these when attending CoG meetings at the main hospital site. Actions: KR would review the issue of printing costs and the parking arrangements at the Trust for when meetings resumed in person. 6.5 Consultation Regarding Timings of Council of Governors’ Meetings At the CoG meeting on 22 January 2022, it had been agreed that a survey of governors would be carried out to identify the preferred times of day for CoG meetings with a view to varying the times of future meetings. This followed the resignation of two staff governors who had been unable to regularly attend meetings of the CoG due to work commitments. Ten responses to the survey had been received. There was a slight preference expressed for meetings to be held at regular times, although no overall majority in favour of regular or varied meeting times. Most governors identified meetings held in the mornings or afternoons to be more convenient and meetings held in the 6 evenings were less convenient for most governors. The CoG was asked to consider: • whether they would like to hold some or all CoG meetings in the morning; • whether they would prefer to hold CoG working group meetings in person when meetings in person were able to resume or whether to continue holding these meetings virtually using Teams would be preferable in terms of securing good attendance; and • if CoG working group meetings were held in person would it most convenient to schedule these on the same day as CoG meetings so that all meetings would be held in person on the same day. Some governors felt virtual meetings made it possible for them to attend more regularly as travelling time was not required and it was noted that attendance at meetings had increased since the introduction of virtual meetings. Virtual meetings also had benefits in terms of reducing congestion on the hospital sites and contributed positively to the delivery of the Trust’s green plan. It was more beneficial to hold meetings in person where these could be combined with a visit to an area of the hospital. Decision: The CoG agreed to retain a mix of meetings in the mornings and afternoons and a combination of face-to-face and virtual meetings once face-to-face meetings could resume. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the membership engagement report highlighting that: • since the last CoG meeting in January 2022 there had been regular engagement with members; • in March 2022 members were informed of the appointment of Jenni Douglas-Todd as new chair of the Trust from July 2022; • as demand for hospital services had increased during April 2022 members had been kept up to date with the latest position and how they could assist by sharing messages to ensure that those who need medical treatment used the most appropriate service; • the Connect newsletter was sent in February and April 2022, with the latter edition split into versions for different constituencies for public members and staff and included details of which governors represented their area and an interview with one of the elected governors; • emails had been sent to all members aged 18 to 30 directly inviting them to take part in a study comparing COVID-19 vaccine doses when used as a third dose at the end of January 2022 and to other members asking them to help share information about recruitment to the study; • targeted emails were sent to members under 30 years of age to publicise a University of Southampton study into the kind of voluntary work, community activities and informal work that young people may have been doing during the pandemic; • the Trust advertised a listening event regarding children and young people with a learning disability organised by our patient involvement team for members with a specific interest in children’s services; • in February 2022 an online survey was launched to help shape the future of the Trust’s membership programme and governors who had provided feedback on the survey prior to its launch were thanked for their support; • KR and SD had attended a listening lunch for carers in Southampton earlier in April 2022, which was organised by the experience of care team; • weekly governor updates including a summary of key staff briefing 7 messages continued to be sent; and • since the last CoG meeting on 26 January 2022, 19 new members had joined the Trust. Future plans included: • supporting the upcoming CoG election in four public constituencies and two staff constituencies; • planning and executing a virtual event for members focusing on research at the Trust in May 2022; • taking part in upcoming community events to promote UHS membership and communicate key Trust messages; and • producing an edition of Connect in June 2022. 7.2 Governors’ Nomination Committee Feedback Feedback from the GNC meeting on 26 April 2022 was provided earlier in the meeting. 7.3 Feedback from Strategy and Finance Working Group In the absence of TW, KR advised that the Strategy and Finance Working Group had met on 21 April 2022. Topics considered had included: • the operational plan 2022/23; • an overview of non-NHS activity; • an update on the annual report and accounts; the process of annual self-certification of the Trust's licence conditions; and • a review of the Strategy and Finance Working Group terms of reference. 7.4 Feedback from Patient and Staff Experience Working Group FQ advised that a meeting of the Patient and Staff Experience Working Group had been held on 20 April 2022. This had been a very interesting session with presentations of the Trust’s new people strategy, the results of the NHS staff survey 2021 and the NHS maternity survey 2021 results. A review of the Patient and Staff Experience Working Group terms of reference was also carried out. 7.5 Feedback from Membership and Engagement Working Group RP advised that a meeting of the Membership and Engagement Working Group had been held on 26 April 2022. The following areas had been covered at the meeting: • SD had attended to provide a membership update and feedback on events held since the last meeting and also provide information on future events; • proposals to introduce an appointed governor for students as part of the composition of the CoG; and • a review of the Membership and Engagement Working Group terms of reference. CR was planning to engage with constituents in the Isle of Wight and RP suggested that all governors be supplied with some paper copies of Trust membership application forms for distribution amongst their constituents. Action: SD would provide a supply of Trust membership application forms to KR for distribution to governors. 8 Any Other Business There was no other business. 8 9 Date of Next Meeting – 19 July 2022 To note the date of the next meeting. RP suggested the meeting was held at its usual time of 2pm, immediately following the separate meeting between the governors and NEDs. There being no further business, the meeting concluded. 9 4 Matters Arising/Summary of Agreed Actions 1 4 Summary of Agreed Actions.docx List of action items Agenda item Assigned to 13 July 2022 10:55 Deadline Status Council of Governors 27/04/2022 7.5 Feedback from Membership and Engagement Working Group 687. Issue of a supply of Trust membership forms for distribution by governors Karen Russell 20/07/2022 Complete Explanation action item RP suggested that governors could be issued with a few Trust membership forms for distribution to promote membership. It was agreed that KR would send a supply to each governor. Explanation Russell, Karen A supply of Trust membership forms were issued to governors on 10 May 2022 as agreed. Council of Governors 27/04/2022 6.4 Council of Governors' Expenses Reimbursement Protocol 686. Reimbursement of printing costs and availability of parking Karen Russell 20/07/2022 Complete Explanation action item RP asked whether governors could be reimbursed for printing papers at home. A further query was raised regarding the availability of parking when face to face meetings resumed. Explanation Russell, Karen As part of the UHS Green Plan and wider sustainability, we want to avoid any unnecessary printing and we would also like to avoid any governors having to incur printing costs when printing at home. To facilitate this, at face to face meetings there will be a free wi-fi connection and a paper copy of the agenda only will be provided. Supporting papers will be displayed on the screen in the meeting room where necessary to support the discussion. On any other occasion which governors are attending an interview or other event where paper copies of any information may be required, these can be printed and provided by the Trust on a more cost-effective basis. A full response was circulated to governors on 23 May 2022. 13 July 2022 10:55 With regard to the availability of parking when attending face to face meetings, KR has arranged with Travelwise to cordon off an area of one of the car parks for use by governors when attending CoG meetings and exit car passes will be provided free of charge for use at these meetings. In view of this governor parking permits will no longer be required. KR will circulate details of the car park which should be used in advance of the next face to face meeting. Council of Governors 31/03/2021 5.5 Amendment to the Trust's Constitution - CCG Merger 444. Review the Council of Governors' Composition Helen Potton/Karen Russell 19/10//2022 Pending Explanation action item A review of the Council of Governors' composition is to be carried out to check that it still remains appropriate. The review was presented to the CoG at the meeting on 21 July 2021. The CoG agreed that volunteers for a task and finish group would be sought to consider the composition of the CoG in more detail. If no volunteers were forthcoming it would be referred to the Membership and Engagement Working Group for further review. Explanation Russell, Karen Following discussions by the Membership and Engagement Working Group, proposals for a change to the composition of the CoG relating to the New Forest, Eastleigh and Test Valley, and Rest of England and Wales constituencies will be presented for approval at the CoG meeting on 20 July 2022. Suggestions regarding young governor representatives were discussed further at the Membership and Engagement Working Group meeting on 27 June 2022. Proposals are to include two young governors as full members of the CoG, one each from the University of Southampton and the UHS Young Adults Group. This will be considered in more detail by a sub group and proposals will then be presented to the CoG. Page 2 5.1 Chief Executive Officer's Performance Report 1 5.1i Report template UHS CoG July 2022.docx Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Chief Executive Officer’s Performance Report 5.1 David French, Chief Executive Officer Jason Teoh, Director of Data and Analytics 20 July 2022 Assurance Approval or reassurance Ratification Information Y Issue to be addressed: Information about Trust performance supports the Council of Governors in their role. Response to the issue: This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Implications: Risks: This report provides performance information relating to a broad range of Trust services and activities, there are no specific implications. This report is provided for the purpose of information. Summary: This report is provided for the purpose of information. Page 1 of 1 1 5.1ii Chief Executive's Performance Report Jul 2022 FINAL.docx UHS Council of Governors 20th July 2022 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. This report covers data from the period from March to May 2022, noting that performance in relation to some of the targets is reported further in arrears. Notable features of the period included: • An increase in the number of COVID-19 inpatients through the period as rates of infection increased across the country. There was also a corresponding increase in the number of hospital-acquired COVID-10 infections. • Extremely high volume of attendances to the Emergency Department, averaging 378 patients per day, an 18% increase on the same period the prior year. • A significant number of patients not meeting the criteria to reside (formerly medically optimised for discharge), usually between 180 – 200 patients, continuing to occupy hospital beds, restricting flexibility in our elective programmes. The number has been as high as 229. Such patients are typically waiting for care to be provided in the community to continue their recoveries or meet long term needs in their home setting. • Referral volumes have exceeded pre-pandemic levels, and despite an increase in hospital activity, the RTT waiting list continues to increase. So far in 2022, the waiting list has grown by 10%. • High numbers of referrals have also been seen for patients with suspected cancer, which have impacted our 2 week wait and 62 Day performance. However, for both metrics, we continue to benchmark in the upper quartile of our teaching hospital peers. • A longer-term trend in higher staff sickness absence continues to rise, with an underlying 0.6-1% of absences in any given week being related to COVID-19. Page 1 of 7 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection Target 95.0% ≥ 90.0% Mar 2022 Apr 2022 67.5% 70.4% 76.9% 79.5% May 2022 67.5% 77.3% Attendances to the main (Type 1) Emergency Department (ED) have continued to increase throughout this period, averaging 378 per day (up 18% on the same period the previous year). UHS four-hour performance has deteriorated; however, we continue to benchmark well against other trusts.. In the period of March to May 2022, UHS ranked in the top quartile of the 16 teaching hospitals that we benchmark against (Type 1 attendances). A related, national, issue is ambulance handover times. UHS continues to maintain timeliness in accepting the handover of patients from ambulance staff, despite challenges this may create within our own department on some occasions. We have maintained handover time between March to May 2022 (despite higher attendances). Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% Mar 2022 67.7% 46,318 Apr 2022 66.4% 48,458 May 2022 68.1% 49,283 Since December 2021, the number of patients on the RTT waiting list has increased by 10%. Referrals have returned to, and are now exceeding, pre-pandemic levels. This means that despite UHS’s activity having increased, we continue to see growth within the waiting list. However, we have made good progress in reducing the longest waiting patients. At the end of May, we only had 10 patients who had waited over two years for treatment (four of which were patient related delays). By the end of June – in line with the NHS requirements – we will have no patients waiting over two years for treatment, apart for any patient requested delays. Cancer Urgent GP referrals seen in 2 weeks Breast symptomatic patients’ referral seen in 2 weeks Treatment started within 62 days of urgent GP referral Target => 93% => 93% => 85% Mar 2022 90.4% 63.6% 72.3% Apr 2022 87.2% 91.7% 74.7% May 2022 86.9% 100% 69.5% There has been improvement within our two week wait (2WW) capacity, particularly within our Breast service as additional consultants have started and the service has run multiple weekend sessions through 2022. There remain some challenges within the Gynaecology and Head & Neck tumour sites – mainly due to higher referrals and staffing challenges. However, despite these performance issues, we continue to benchmark in the top quartile for performance relative to our teaching hospital peers. As a result of referral and treatment challenges, our 62 day cancer treatment performance has been adversely impacted. This is partly due to higher referral volumes, alongside late tertiary referrals, but also highlights some challenges that we have within existing pathways. We are working with the Wessex Cancer Page 5 of 7 Alliance to review, and optimise, relevant cancer pathways. Despite the challenges, UHS continues to benchmark in the upper quartile compared to our peer teaching hospitals. 5. Finance The Trust has now submitted its annual accounts to NHS England and NHS Improvement for 2021/22 reporting a small surplus of £0.05 million from a revenue position of over £1.2 billion, once items deemed as “below the line”, such as impairments to the valuation of our fixed assets, were removed. This met the national minimum breakeven mandate required for NHS organisations. Supporting this delivery was the achievement of £15 million of efficiencies in year, which, although below previous years’ levels, was a significant achievement given the level of operational pressure. Operating income increased £160 million from the previous financial year with significant funding increases related to the UK Health Security Agency saliva mass testing programme contract and also increases in research and development income due predominantly to COVID-19 vaccine studies. Additionally, NHS income continued to grow both in line with funding settlements and inflationary awards together with service expansions and elective recovery funding. Spend increased in equal measure however, with pay spend increasing by £57 million from the previous year. The trusts capital programme for 2021/22 also closed on plan with delivery in full to capital departmental expenditure limits (CDEL). Spend totalled £65 million, including investment in new theatres, expanding our emergency department and expanding our ophthalmology capacity. The underlying financial position of the trust is however more challenging, with inflationary pressures particularly within energy costs, a continuation of covid spend mainly on staff sickness/absence backfill, and drugs cost growth in excess of block funding levels, all creating financial pressure. The trust has however submitted a breakeven plan for 2022/23 which is predicated on the delivery of cost improvement plans totalling £45m (4%). For April and May the YTD position is a £5m deficit which is £2.2m below planned levels as a deficit had been anticipated in earlier months of the year knowing that traction on the trusts savings programme would take time to establish. The gap to plan is mainly driven by covid costs greater than forecast in addition to slower than anticipated delivery of cost improvement plans. Increased focus is now being applied in this area to ensure financial improvement is delivered and the breakeven plan for the year can be achieved. Capital spend is on plan year-to-date however much of the spend is profiled to later months with wards developments, MRI replacements and theatres expansion all planned for the second half of the year. Page 6 of 7 6. Human Resources Indicator Target Staff FFT - % of staff who agree or strongly agree that they would recommend UHS as a place to work Staff recommending UHS as a place to receive care/treatment => 75.5% => 85.0% Q4 21/22 73.8% National Average (Acute / Acute + Community Trusts) Picker average 58.4% 59.2% 84.9% 66.9% 66.8% The national NHS Staff Survey 2021 opened from September to November 2021 inclusive. Results are sent to individual trusts January to March, with embargo lifted in March 2022. Staff Survey results are now aligned to the NHS People Promise themes. UHS had a response rate of 56.2% (6,985 staff), representing a 6% increase from 2020. UHS scored average or above average on all seven themes. Our aim is to continue to improve, strive to increase our scores where all scores are above average in 2022, and aim for being the “best” scoring wherever possible thereafter Indicator Turnover (internal target) Sickness absence 12 month rolling (internal target) Nursing Vacancies (Registered Nurse only in clinical wards) (internal target) Target <=12% <=3.4% <=15% Mar 2022 14.3% 4.5% 12.8% Apr 2022 15.8% 4.6% 13.0% May 2022 14.9% 4.7% 13.6% Primarily reasons for sickness included: Covid-related sickness (including long Covid); work-related stress; and MSK. There has also been a recent increase in short-term sicknesses. End. Page 7 of 7 6.1 Non-Executive Director Reappointment and Appointment of Deputy Chair 1 6.1a Non-Executive Director Reappointment and Appointment of Deputy Chair front sheet v2 updated.docx Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Non-Executive Director Reappointment and Appointment of Deputy Chair 6.1 Jenni Douglas-Todd, Trust Chair Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 20 July 2022 Assurance Approval or reassurance Y Ratification Information Issue to be addressed: Response to the issue: Implications: Risks: Summary: The first three year term of office as a non-executive director for Tim Peachey will come to an end on 30 September 2022. Non-executive directors are eligible for reappointment for a second three year term subject to reappointment by the Council of Governors. One of the roles of the Governors’ Nomination Committee is to make recommendations to the Council of Governors on the reappointment of non-executive directors. The constitution provides for the appointment of a deputy chair. Jane Bailey is the current deputy chair and has resigned from that role as at the end of July 2022. It is proposed that Tim Peachey is reappointed for a second three year term of office. The attached paper provides details of the outcome of appraisals, changes to commitments and ongoing independence and commitment to the role. In terms of the deputy chair position it is proposed that a recommendation is made to the Council of Governors at their meeting on 19 October 2022. The appointment and reappointment of non-executive directors is one of the statutory responsibilities of the Council of Governors role following recommendation by the Governors’ Nomination Committee. The appointment of the deputy chair is one of the responsibilities of the Council of Governors. 1. Failure to ensure an appropriate balance of executive and independent non-executive directors in accordance with the Trust’s Constitution and The NHS Foundation Trust Code of Governance. 2. Ensuring the appropriate balance of skills and experience among the non-executive directors on the Board. 3. Ensuring the effective functioning of the Board. The Council of Governors is asked to approve Tim Peachey’s reappointment as a non-executive director for a second three year term commencing on 1 October 2022 on the same terms and conditions as his current appointment. The Governors’ Nomination Committee will be Page 1 of 2 asked to review the proposed reappointment at its meeting in July 2022 and will provide its recommendation to the Council of Governors. The Council of Governors is asked to approve the recommendation to defer the appointment of a deputy chair to the meeting on 18 October 2022 following a recommendation made by the newly appointed chair. Page 2 of 2 1 6.1b NED Reappointment and Appointment of Deputy Chair paper v2 updated.docx Non-Executive Director Reappointment and Appointment of Deputy Chair 1 Non-Executive Director Reappointment Background In September 2019 the Council of Governors (CoG) appointed Tim Peachey as a nonexecutive director for an initial three year term commencing on 1 October 2019. Nonexecutive directors are eligible for reappointment for a second three year term subject to reappointment by the CoG. When considering the reappointment of a non-executive director, the Governors’ Nomination Committee and the CoG should consider: • the outcome of the non-executive director’s appraisals since appointment; • their other commitments and the time available for the role; and • independence. Annual appraisal Tim Peachey has been subject to satisfactory appraisal annually since his appointment in 2019. Governors have had the opportunity to contribute to the appraisal of the non-executive directors each year by providing feedback through the Lead Governor. The most recent appraisal was carried out in February 2022. Following appraisal, the then Chair, Peter Hollins, confirmed that: • following formal performance evaluation, Tim Peachey’s performance as a nonexecutive director continued to be effective and demonstrated his commitment to the role; and • he would have no hesitation in recommending Tim Peachey for reappointment to the role following the appraisal process. Other commitments Since his original appointment, Tim has ceased his role as clinical safety officer of Block Solutions Ltd and taken on the role of Health Advisory Board member at Palantir Technologies UK, Ltd. Tim currently performs the following roles in addition to his role as a NED for the Trust: • Director, TP-Medcon Ltd • Clinical Advisor, Bolt Partners Ltd • Associate - Mediator, Problem Resolution Ltd • Non-Executive Director and Chair of Quality Committee, Isle of Wight NHS Trust • Health Advisory Board member, Palantir Technologies UK, Ltd. Tim has indicated his willingness to be reappointed for a further three year term and confirmed that he continues to have the time to commit to the role. This has been demonstrated through his attendance at meetings, which was considered as part of the appraisal process. 1 Independence Non-executive directors should be independent in character and judgement. Tim Peachey was considered to meet the requirements for independence applicable to a non-executive director on appointment. In his performance as a member of the Board of Directors and Audit and Risk Committee, chair of the Quality Committee and as the non-executive Maternity Safety Champion, Tim has continued to demonstrate his independence and constructive challenge. Since his appointment Tim has been subject to annual fit and proper persons checks and declaration processes applicable to directors to confirm ongoing compliance with the requirements. Recommendation Subject to recommendation by the Governors’ Nomination Committee, the Council of Governors is asked to reappoint Tim Peachey as a non-executive director for a second three year term commencing on 1 October 2022 on the same terms and conditions as his current appointment, including the current annual fee of £14,000 as remuneration for the role and the fee of £2,000 for additional chairing responsibilities in respect of the Quality Committee. 2 Appointment of Deputy Chair Background The appointment of the Deputy Chair is made by the Council of Governors. The current postholder, Jane Bailey, has advised that she intends to step down from the role as at the end of July 2022. When considering the appointment of a new Deputy Chair it would be usual for the view of the Chair of the Trust to be taken into consideration and a recommendation for approval be made. Recommendation Following the recent appointment of Jenni Douglas-Todd to the position of Chair of the Trust, it is recommended that a paper would be presented to the Council of Governors on 19 October 2022 with a recommendation in relation to the appointment of a Deputy Chair. 2 6.2 Amendments to the Constitution 1 6.2a Amendments to Constitution - cover sheet v2 updated.doc Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Amendments to Constitution 6.2 Jenni Douglas-Todd, Trust Chair Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 20 July 2022 Assurance Approval or reassurance Y Ratification Information Following a review of the composition of the council of governors of the Trust, the council of governors has agreed to alter the number of governors elected by the areas of the public constituency to ensure that these remain representative of those to whom the Trust provides services. Having reviewed the current areas of the public constituencies and the proportion of patients seen by the Trust from those areas, the following proposed changes have been agreed: • to reduce the number of governors representing the Rest of England by one governor; and • to increase the number of governors representing New Forest, Eastleigh and Test Valley by one governor. The council of governors has also agreed to maintain a representative on the council of governors from local commissioners as an appointed governor, following the transfer of functions from NHS Hampshire, Southampton and Isle of Wight Clinical Commissioning Group to NHS Hampshire and Isle of Wight Integrated Care Board taking effect on 1 July 2022. Other minor changes are proposed to be made to the current constitution identified as part of this review and to correct minor typographical and other errors. These changes include: • to reflect the transfer of functions from Monitor/NHS Improvement to NHS England from 1 July 2022; • to update the model election rules attached at annex 4 to the constitution to those published by NHS Providers in August 2014 (these have not yet been updated to reflect the transfer of functions from Monitor to NHS England, however references to Monitor should be read as referring to NHS England); • to remove appendix 4 to annex 8 as it duplicates provisions in paragraph 25 of the constitution, as amended, and the terms of reference for the governors’ nomination committee; • to remove references to registers in paragraph 35 that are no longer maintained, or required to be maintained, by the Trust; • to all
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